Case Manager/ Utilization Review

Under the general supervision of the Manager, nurses in the Case Manager role provide clinically based case management to support the delivery of effective and efficient patient care.   Paces cases from physiological and economic perspectives.  Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement.  Utilizes criteria to confirm medical necessity for admission and continued stay.  With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources.   

This opportunity is Registry Role 8am - 4:30pm. Rotate every other weekend

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information.  Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation.  Documents information in the current electronic system (such as MIDAS).

2. Validates admission and continuing stay criteria with third party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians.  Recommends alternative care sites where appropriate.  

3. Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.  Intervenes to prevent the denial where possible.

4. Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.

5. Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team.   Uses knowledge of usual length of stay to initiate a plan for discharge.

6. Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan.   Supports the process of patient choice in establishing a discharge plan.

7. Uses clinical knowledge and knowledge of anticipate response to treatment to assess patient progression towards anticipated outcomes.  Communicates and coordinates with the patient/family and health care team to Intervene when progression is stalled or diverted.  Addresses actual/potential barriers to discharge

8. Completes the interventions necessary for discharges to home with self-care, home with services and short term skilled nursing facility placement.  Assembles necessary referrals, discharge summaries and pertinent information for placement prior to the day of discharge.  

9. Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.

10. Identifies high risk patients and creates a collaborative plan to address their unique needs

11. Other duties as assigned.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience  

• 3 to 5 years' experience in acute care Nursing required. Preferred 3 years' experience as a Case Manager in an acute care setting.  
• Associate’s degree required, bachelor's in nursing preferred
• Current Illinois RN Licensure required.
• Must have strong interpersonal and communication skills.
• Ability to form positive, collaborative relationships with hospital staff, patients and families.
• Ability to effectively negotiate with internal and external providers of patient care services.
• Must have analytical abilities to asset in obtaining solutions to problems.
• Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.
• Ability to effectively negotiate with internal and external providers of patient care services.

Community First Medical Center is an affirmative action/equal opportunity employer who is committed to cultivating diversity, equity and inclusion within all aspects of our organizations. We stand against and prohibit discrimination in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.